Office Only G CASE # Application and Self Assessment Form Princess Marina House Rustington, West Sussex BN16 2JG Print Name (First, Last, Middle Initial). Application Form, Self Assessment Form, Financial Assistance Request
Application Form for a Short Welfare Break Princess Marina House, Rustington, West Sussex, BN16 2JG 01903 784044 01903788970 www.rafbf.org/princess-marina-house This questionnaire is strictly confidential and will become part of your medical record. Details of Service on Whom Eligibility is Based Applicant Yes No Name (Last, First, M.I.): M F I like to be known as DOB: Marital status: Single Partnered Married Separated Divorced Widowed Maiden Name : RAF Service Number: Rank : Branch /Trade From to National Insurance Number War Disability Pensioner Yes No If Deceased, Date of Death New applicants only, please attach photocopy of Death Certificate NHS Number Details of Eligible Applicant (if not above) Relationship to Person at Section A Name (Last, First, M.I.): M F DOB: Date of Marriage National Insurance Number NHS Number Details of any other person accompanying applicant Relationship to Applicant Date of Marriage Name (Last, First, M.I.): M F DOB: NI Number NHS Number Address 1
Address of Applicant Postcode Type of accommodation House Flat Bungalow Care Home Other Home Phone Number Mobile Phone Number Next of Kin/ Other family/ significant other Relationship to Applicant Name Address Telephone Number Friends and Family who support me Name Address Telephone Number Name Address Telephone Number Health Care Professional e.g. Doctor, District Nurse, Social Worker Name Address Telephone Number If you have the following please bring them with you Copy of your Lasting Power of Attorney for health and welfare Copy of your Lasting Power of Attorney for financial affairs A do-not-resuscitate order, (DNR order) written by a doctor. (please note original only will be accepted by health care professionals) Advanced Care Plan 2
Your stay Period of stay requested is from to I would prefer to arrive on Monday Tuesday Wednesday Thursday Friday I would like to stay for One week Two weeks Three weeks Four weeks I would like the tariff Full board Half board Bed and breakfast I need days notice or I can accept a cancellation at short notice State briefly reason for break.. How did you hear about Princess Marina House? I will be using my own car : registration number: I will be getting a lift I will be coming by train arriving at station I will be coming by coach arriving at Do you need financial Assistance to pay for this? Please see Page 4 if you do If you would like to be assessed for Financial Assistance from the RAFBF to cover the cost of you stay and or transport to Princess Marina House to arrange a case worker appointment please contact RAFA Helpline 0800 018 2361 www.rafa.org.uk SSAFA Helpline 0800 731 4880 www.ssafa.org.uk A case worker will visit you at home to complete Section I of the application form. Please have all documents available. If you don t require financial assistance please just complete and sign Section II and return this booklet to Princess Marina House Enquiries about applications can also be directed to info@rafbf.org.uk or by calling 0800 169 2942 3
Section I Financial Assessment APPLICANTS WEEKLY HOUSEHOLD INCOME & EXPENDITURE (verified from relevant documents) Is the applicant, to the best of your knowledge, in receipt of all applicable state benefits, rebates and allowances? Yes No What action is being taken?... Owner occupier or tenant?... EXPENDITURE Verified Weekly Arrears INCOME Rent (less Housing benefit) Earnings of Applicant (inc. overtime but less Tax and NI) Mortgage Earnings of spouse/partner Council Tax Job Seekers/Income Support Housekeeping Statutory Sick/Maternity Pay Gardener Maintenance received Electricity State Retirement Pension Gas Service Pension Water Rates Occupational Pension Other Fuels War Disablement Pension ( %) Insurance (not NI) Pensions Spouse Television Disablement Pension ( %) Satellite Incapacity Benefit Employment Support Allowance Telephone Widows Pension (War/NI) Broadband Child Benefit/Special Allowance Taxi/Bus fares Working Tax Credit Car Universal Credits Scooter/EPV costs Industrial Injuries Disablement Benefit Personal/Debts/loans/HP Severe Disablement Allowance Hairdresser Disability Living Allowance Care Component Pets (state if guide/assistance Disability Living Allowance dog) Mobility Component House Repairs Attendance Allowance Window Cleaner Disability Working Allowance Cleaner Pension Credit Carer Carers Allowances Prescriptions Other income (give details) Alternative therapy Other (please specify) Total Total Savings/Capital/Investments Please show amount of savings e.g. Bank, Building Society, etc. Verified Weekly Any other long term investments? State what they are 4
Welfare officer/helper s report and recommendation This statement should give a description of the circumstances of the applicant, what the need is and the opinion of the Case Worker. Please use an additional sheet, if necessary. Case Workers Signature Mr/Mrs/Miss/Mrs/Other Name (PLEASE PRINT) Address Postcode Email Address Branch Telephone Date 5
Declaration I declare that the information that I have given on this form is correct to the best of my knowledge. I agree that the information supplied on this form may be shared with voluntary or charitable organisations and relevant statutory agencies for the purpose of furthering my application for assistance. The person whose details are being requested is deceased, or unable to sign, evidence of which is enclosed (See notes below). The person whose details are being requested in order to process the application is unable to sign for the following reason (See notes below). Signature of Client: Date: Signature Print name Relationship Date Lasting Power of Attorney for health and welfare Lasting Power of Attorney for financial affairs attached attached In line with Information Law personal information regarding a client cannot be disclosed without their consent. However, there are cases where the Serving/ex-Service person is unable to sign. In such cases, further information should be supplied to the relevant service verification office in order to confirm service. The following cases illustrate what information should be provided: Where the ex-service person has died, the verification form should be accompanied either by a death certificate, or proof of death i.e. invoice from undertaker or confirmation of bereavement allowance or widows pension. In cases where the Serving/ex-Service person is infirm or physically unable to sign, a copy of power of attorney and the attorney s consent should be provided. Where there is no power of attorney a note from a medical professional explaining the client s incapacity will suffice. In cases of estrangement, where the Serving/ex-Service person has not signed, and as much information as possible is provided-the Service Verification offices will be able to confirm or deny service, but in line with Information Law, no further details can be released. 6
OFFICE USE ONLY Section II Applicant s Health Self Assessment GCASE Number Print Name (first and surname ) Have you ever been diagnosed with any specific medical conditions or ongoing difficulties with : Alzheimer s Disease (Carers please fill in section About Me ) Arthritis/ Joint Replacements/ Fractures Asthma Bowel Disease Dementia (Carers please fill in section About Me ) Depression Diabetes Epilepsy Heart Disease High Blood pressure Kidney Problems Neurological Disorders Obsessive Compulsive Disorder Parkinson s Disease PTSD Recent Surgery Respiratory Disease Skin Conditions Stroke/TIA s Urinary Tract Infections Wound Care I have no dressings Other (please name) Please advise if you have any wounds or ulcers that will require attention during your stay. Yes I have dressings: Where?.. They require changing : When?.. 7
Personal care Do you have professional carers visiting you at home? (Tick one box) If yes, how many times each day? Please state number of times. Washing and Bathing (Tick one box) I do not currently have any support at home. I can bathe independently. Go to the next question I have part time family member or friend who helps me at home. ------ times a day I can shower independently but require assistance for a bath. I have a family member or a part time carer who helps with my personal care and other issues around the home. -------times a day I require the assistance of one carer to maintain my personal hygiene. I have a live in family member or full time carer or I currently live in a care home and am supported 24 hours a day. -------- times a day I require the assistance of 2 carers to maintain my personal hygiene. Dressing (Tick one box) I can dress independently. Go to the next question I need support with zips, buttons and hosiery. I require the assistance of one carer to help me dress I require the assistance of 2 carers to help me dress. The support I need with things like dressing, washing and teeth cleaning is... 8
Toileting (Tick one box) I am independent Go to the next question I am independent with a toilet frame or raised seat. Go to the next question I require the assistance of a carer. I require the assistance of two carers and a commode at night. Continence (Tick one box) I am continent Go to the next question I use pads to maintain my independence. Go to the next question I am incontinent of urine and require assistance from a carer and continence aids. I am doubly incontinent and require full assistance from two carers. How I use the toilet when I am well e.g. continence aids and getting to the toilet... Additional Information Protection to bed Pads used Catheter Stoma Bag Weight Under 12 stone 12 to 15 stone 15 20 stone Over 20 stone 9
Eating & Drinking Do you have any special dietary requirements? If yes please tick relevant box Diabetic Gluten Free Low Fat Yes No Yes Yes Yes Other (Describe) Please attach your diet sheet Now please tick yes to one of the following I can eat and drink independently. Providing food is cut up I can eat and drink independently. Providing food is liquidized I can eat and drink independently. I require some assistance with eating and drinking. I require supervision at all times while I am eating and drinking. Yes Yes Yes Yes Yes Do you have any food allergies? If yes please write them here Choking If there is a risk you may choke please give details of your management plan and seating & posture 10
Medication I do not take any medication I do take medication and I am able to self medicate I will need reminding to take my medication but I am able to give it to myself My medication needs to be given to me by my carers One tablet at a time Via a syringe On a spoon I need help to make sure I have swallowed Have you been prescribed any of the following drugs in the last two years? Sedatives/Tranquilisers e.g. Trazidone, Diazepam, Lorazepam, Estazolam Yes No Anti psychotic drugs e.g. Chlorpromazine Amisulpride, Haloperidol, Pimozide, Trifluoperazine Sulpiride Clozapine Olanzapine Quetiapine, Risperidone Yes No Remember to bring with you An up to date repeat prescription All your medication in a pharmacists blister pack or original packaging List your prescribed medication or attach a copy of your most recent prescription. Name the Drug Strength Frequency Taken Allergies to medications Name the medication Reaction You Had 11
Mobility Please bring your own walking frame/rollator. We are unable to provide these for you I have no mobility issues. I am mobile both indoors and outdoors without assistance. Go to the next question I am mobile with the use of an aid indoors and am able to sit and stand independently. Please indicate type of aid in box below headed additional information Are you able to use stairs? I am mobile with an aid but require assistance in getting up and sitting down and transferring. Please indicate type of aid in box below headed additional information. I have no mobility without carer and assistance. Please indicate type of aid in box below headed additional information. Yes No Are you a wheelchair user? Yes No Is your wheelchair electric? Yes No Do you require an electric mobility scooter if available? Yes No Do you require wheelchair if available? Yes No Additional Information e.g. What equipment do you use in your home? Walking stick Profiling or Hospital Bed Crutches Standing Hoist Zimmer Frame Full Body Hoist Wheeled Frame Turntable History of falls (Tick one box) No history of falls Go to the next question I have occasional falls but I am usually able to get up unaided I fall frequently but I am usually able to get up unaided If I fall I need to be hoisted 12
Keeping me safe - Do I explore? Could I fall out of bed? Please consider environmental risks Sleep Patterns (Tick one box) I have no problems with my sleep pattern. Go to the next question I have occasional problems with sleeping. I take medication to sleep well at night. I may require some reassurance. I have trouble sleeping at night and may require support from a carer. How I usually am for example do I sleep a lot, am I usually very quiet? Communication Sight (Tick one box) Hearing (Tick one box) No sight issues. I have no hearing issues. I wear glasses/contact lenses and require carer support with these and help cleaning them I have hearing aids /issues but manage with minimal help. I know how to put it in and turn it on I am registered blind / partially sighted and require assistance from the carers. I have hearing aids / issues and need assistance putting it in and turning it on I am blind / partially sighted and use a guide dog and will require support from the carers. I am registered as being deaf and require a large amount of support. 13
Speech (Tick one box) I have no speech issues. I can communicate without help. I have speech difficulties but can communicate without difficulty. Other ways I communicate if applicable Signing, pictures or other languages? My speech is distorted and may require extra support to be understood. I am unable to verbally communicate I communicate using aids. How I show how I feel. How I communicate yes and no. Understanding (Tick one box) I have no problems understanding people or remembering information I have occasional difficulty remembering information How I show I m in pain and how to support me I have memory loss which affects my day-to-day living and / or I have been diagnosed with dementia in the last two years. I have memory loss which affects my ability to care for myself and/or have been diagnosed with dementia more than two years ago. I agree that information collected as part of the application process may be retained so that any future applications may be speedily processed, and that data generated may be used for follow up assistance, statistical and research purposes. I confirm that the information I have provided in the above assessment is a true indication of my care needs. I give permission for The Royal Air Force Benevolent Fund to contact my GP or any other Health Care Professional if there are any concerns relating to the information I have given. Signature Print Name.. Date 14
About Me ONLY FILL THIS SECTION IF YOU TICKED been diagnosed with Alzheimer s Disease or Dementia on page 7 Are you prone to infection? Yes No If yes, Urine Chest Other In the event of an infection have you ever Become verbally aggressive? Become paranoid (suspicious of people around you)? Become delusional? Thrown or broken anything? Hit out at person/persons? How do you react to strange places? Yes No Yes No Yes No Yes No Yes No Do you become anxious at any particular time of day? Yes No If yes, when? How is this displayed? tick any box Wandering Inability to sit still Constant questioning Accusations of persecution Verbal aggression Throwing things Hitting out 15
Things that may worry or upset me (foods, activities ) How I may show this How to support me if I am anxious or upset Behaviors I have that may be challenging or cause risk. What you can do to support me with my behaviors things that help me relax Things I like include: Music, TV, foods, activities and how I relax 16
My History- What is important that you know about my life (past and present) including previous employment If this section is completed by a family member or carer please sign in the box below Signature Date Relationship to applicant Declaration Data Protection Act The information provided by the applicant is given in confidence and is subject to the Data Protection Act 1998. The Royal Air Force Benevolent Fund may share this information with third parties in order to seek/secure further funding. Thank you for taking the time to complete this form. 17
For more information about the RAF Benevolent Fund and its work visit www.rafbf.org Royal Air Force Benevolent Fund, 67 Portland Place, London, W1B 1AR 020 7580 8343 Cobseo The Confederation of Service Charities The RAFBF is a registered charity in England and Wales (1081009) and Scotland (SCO38109)